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1 Early Detection of Vestibular Disorders in Individuals with Brain Injury Jordana Gracenin PT, DPT Sara Schwartz PT, DPT, NCS Objectives 1. The learner will be able to identify anatomy and physiology of peripheral and central vestibular systems. 2. The learner will be able to identify common presentations of peripheral vs. central vestibular disorders. 3. The learner will be able to list contraindications for positional testing for peripheral vestibular disorders. 4. The learner will be able to identify appropriate assessment techniques for central vs peripheral impairments. 5. The learner will be able to identify appropriate treatments for a variety of disorders/impairments related to those with traumatic brain injury 6. The learner will be able to apply knowledge to demonstrate understanding of material using multiple cases of patients with vestibular dysfunction. 1

2 Vestibular System Function Linear and angular accelerometer Rotational movements of the head Linear movements of the head Head position in space With this information Gaze Stability Balance and Postural Stability Orientation in Space Vestibular System Dysfunction Oscillopsia Dysequilbrium Abnormal Sense of Movement/Orientation Decreased Visual Acuity with head movements and mobility Ataxia Imbalance Anatomy: Peripheral Vestibular System Semicircular canals Anterior Posterior Lateral Otoliths utricle saccule Vestibular ganglion Vestibular nerve 2

5 Oculomotor Exam Spontaneous Nystagmus Gaze Holding Nystagmus Eye Movement Range of Motion Vergence Smooth Pursuits Saccades VOR Cancellation Examination: Contraindications and Precautions for Positional Testing Contraindications Retinal detachment Precautions* Vertebro-basilar insufficiency Neck instability or recent neck trauma History of Neck Surgery Cervical myelopathy or radiculopathy Carotid sinus syncope Vascular dissection syndromes Severe Rheumatoid Arthritis Craniectomy Examination: Dix-Hallpike Start with person in long sitting on the table so that when they lay back, their head will be off the table Turn the head 45 degrees toward the side least suspected as having displaced otoconia Secure the person s head and torso and lay them back placing their neck in degrees of extension Have person keep his/her eyes open so that you can observe for nystagmus. Positive test indicated by reports of vertigo and observation of torsional upbeating nystagmus 5

6 Examination: Roll Test With the person in supine, head flexed 20 degrees and facing forward, turn the head to one side and observe for nystagmus and corresponding symptoms Hold the position for up to 1 minute to observe for symptoms May perform to both sides Categorize the nystagmus as apogeotropic vs geotropic to assist in deciding which is the affected side as you are stimulating both canals with this test Lateral Canal Diagnosis Geotropic-side of greatest intensity of nystagmus is the side involved towards ground Apogeotropic-side of least intensity of nystagmus is the side involved Away from ground Benign Paroxysmal Positional Vertigo Treatment in Traumatic Brain Injury May require more sessions 67% of patient with benign paroxysmal positional vertigo following traumatic brain injury required repeat PT sessions vs 14% of patients with idiopathic benign paroxysmal positional vertigo 57% of patients with benign paroxysmal positional vertigo following traumatic brain injury had recurrent attacks, vs 19% of patients with idiopathic benign paroxysmal positional Gordon,

8 Picture Alternative Testing Positions Treatment: Canalith Repositioning for Posterior Canal Benign Paroxysmal Positional Vertigo For Canalithiasis After completing the Dix-Hallpike maneuver, the patient is supine with the head turned 45 degrees to the involved ear and is in degrees of extension Hold this position 2x longer than length of observed symptoms Maintain neck extension and rotate head 45 degrees to the opposite side. Hold this position 2x longer than duration of symptoms Have the person roll onto their side (opposite of affected ear) and turn head down 90 degrees toward the ground, while keeping the chin tucked Keep the head in this position and help the person slowly sit up at the edge of the table. Bring head into neutral once the person is in the full sitting position Treatment: Canalith Repositioning for Posterior Canal Benign Paroxysmal Positional Vertigo For cupulolithiasis Liberatory Maneuver/Semont Maneuver Sidelying on involved ear 180* turn to sidelying on uninvolved ear **Change in position should take ~1.3 seconds Goal is to convert to canalithiasis Complete previously described posterior canal repositioning maneuver Helminski,

9 Treatment: Horizontal Canal BBQ Roll (Lempert Maneuver) Person starts in supine with the neck flexed 30 degrees (end of Roll Test) Slowly roll the head toward the affected ear (maintain neck flexion) Roll the head back to neutral and hold 2x longer than duration of symptoms Roll the head to the opposite side (involved ear up) and hold 2x longer than duration of symptoms Have the person roll onto their stomach propped on elbows and rotate the head until the person is face down with neck flexion maintained and hold 2x longer than duration of symptoms Help the person transition into sitting Treatment of Benign Paroxsymal Positional Vertigo: Was I Successful? Re-test 24 hours after treatment Reduces likelihood of false negative Treatment is more effective with repetition in same session Critical analysis of nystagmus during repositioning Reversal of nystagmus during maneuver Rotational vs horizontal Importance of Early Treatment Generally good results with Canalith Repositioning Maneuver Allows for rehabilitation to focus on balance deficits that may linger after BPPV and/or vestibular dysfunction is managed 9

11 Case Example: DB Vestibular Assessment (+) Dix-Hallpike on the left Performed Canalith repositioning maneuver for left ear canalithiasis x2 with reduction in symptoms Re-tested next day: nystagums in 2 nd position (+) Dix-Hallpike on the Right Performed Canalith repositioning maneuver for right ear canalithiasis x2 with reduction in symptoms Initiated VORx1 in seated position Functional Improvements at D/C Berg Balance improved 46/56 Gait speed 1.1 m/s Case Example: MS History Present Illness: 81 year old female admitted status post mechanical fall Imaging: Subdural hematoma Initial PT Evaluation: Minimal Assistance for all functional mobility Multiple falls in the past year Pt reports difficultly sleeping, double vision, headache with reading and sleeps with 5 pillows at night Case Example: MS Vestibular Assessment (+) Dix-Hallpike on the left Performed Canalith repositioning maneuver for left ear canalithiasis x2 with reduction in symptoms Completed 3 more times (-) Dix Hallpike on the right Functional Improvements at D/C Improved Sleep Able to read a book without a headache Can sleep with 1 pillow 11

13 Case Example: CR Vestibular Assessment: Right Dix Hallpike (+) Canalith repositioning maneuver performed twice with symptom resolution and no nystagmus after second maneuver Bilateral Dix Hallpike and Roll tests (-) the next day Functional Improvements: Able to get out of bed with supervision only Gait speed.54m/s Case Example: MM History of Present Illness: 38 year old female presenting after fall out of a moving bus Imaging: Right temporal non-displaced calvarial fracture extension into right temporal bone, left subarachnoid and intraparenchymal hemorrhages, left temporal hemorrhagic contusion and nasal fractures, right lateral malleolus fracture Case Example: MM Initial Evaluation: Unable to formally test balance secondary to non-weight bearing right lower extremity Smooth pursuits, saccades normal, R beating nystagmus with R horizontal end gaze Dizziness getting in and out of bed and with standing up Having trouble reading Orthostatic Vestibular Examination: Right Dix-Hallpike (+) Canalith repositioning maneuver completed 4x with improvement of nystagmus and patient reported dizziness Recommended to remain upright Retest next day (-) 13

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